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    Naeny Blegur
    1. A 23-year-old male patient presented to the emergency room with wounds covering his entire body after being involved in a traffic accident where he collided with a meatball cart. 2. On examination, he had second degree burns over 34% of his body as well as lacerations and abrasions. 3. The treatment plan included wound cleaning, IV fluid resuscitation, pain medications, antibiotic ointment, and monitoring urine output.

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    BDNDBDBDB

    Uploaded by

    Naeny Blegur
    16 views11 pages
    1. A 23-year-old male patient presented to the emergency room with wounds covering his entire body after being involved in a traffic accident where he collided with a meatball cart. 2. On examination, he had second degree burns over 34% of his body as well as lacerations and abrasions. 3. The treatment plan included wound cleaning, IV fluid resuscitation, pain medications, antibiotic ointment, and monitoring urine output.

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    1. A 23-year-old male patient presented to the emergency room with wounds covering his entire body after being involved in a traffic accident where he collided with a meatball cart. 2. On examination, he had second degree burns over 34% of his body as well as lacerations and abrasions. 3. The treatment plan included wound cleaning, IV fluid resuscitation, pain medications, antibiotic ointment, and monitoring urine output.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    16 views11 pages

    BDNDBDBDB

    Uploaded by

    Naeny Blegur
    1. A 23-year-old male patient presented to the emergency room with wounds covering his entire body after being involved in a traffic accident where he collided with a meatball cart. 2. On examination, he had second degree burns over 34% of his body as well as lacerations and abrasions. 3. The treatment plan included wound cleaning, IV fluid resuscitation, pain medications, antibiotic ointment, and monitoring urine output.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 11

    MORNING REPORT

    MEY 21TH 2018 (14.00-21.00) DM RIA,


    KONSULEN DM ZUHAIFAH
    DR. ALDERS NITBANI, SP.B
    PATIENT I
    Name : Mr. MT
    Age : 23 yo
    Gender : Male
    Address : Bakunase
    ANAMNESIS
    Chief complaint: wounds on the whole body after traffic
    accident
    Present Complain :
    The patient came to ER because he had wounds on the whole
    body. 1 hour before, he has traffic accident when he wants to
    go to the market. He said that he hit the cart seller of meatballs
    and then he fell. His chest was hit the road, after that the cart
    seller of meatballs fell and hit the patient. The meatball’s sauce
    was spill on his whole body. Dizziness (-), vomiting (-), double
    vision (-), blood out of ear (-) and nose (+).
    PRIMARY SURVEY
    A : Clear
    B : RR : 28x/mnt, Chest expansion symetric
    C : BP : 120/60mmHg, HR : 50x/mnt, regular
    D : GCS E4 V5 M6
    E : Combustio grade II B 34%
    SECONDARY SURVEY
    GCS : GCS E4 V5 M6, Time and people oriented good
     Head : lesion (+)
     Eye : Conjunctiva anemis -/-, pupil isocor RCL +/+,
     Ear : Otorrhea (-)
     Nose : epistaxis (+), rinorhea (-) lesion (+)
     Neck : Lymphadenopathy (-)
    THORAX
    lesion (+)
    Lung
     Inspection : Chest expansion symetric,
     Palpation : Vocal fremitus (R=L), mass (-),
    crepitation (-)
     Perkution : sonor (+/+)
     Auscultation : Vesiculer (+/+) , Ronchi (-/-), Wheezing
    (-/-)
    Heart:
     S1/S2 single, murmur (-), gallop (-)
    ABDOMEN
     Abdomen
     Inspection : flat, lesion (+)
     Auskultation : peristaltic sound normal
     Palpation:
     distended (-) Defans Muscular (-) tenderness of
    epigastrium (-)
     Percussion :
    Tympani (+)
    EXTREMITIES
     Upper Extremities
     Look : lesion (+) , deformity (-)
     Feel : warm, CRT <2 sec (+), A. Radialis pulse D/S (+/+)
    Lower extremities
     Dextra :
     Look : lesion (+)
     Feel : warmer, CRT <2 sec (+)
     Sinistra :
     Look : lesion (+)
     Feel : warmer, CRT <2 sec (+), pulsation A. Dorsalis pedis (+)
    LOCALIZED STATUS
    a. Combustio grade II B 34%
    ASSESMENT
    Combustio grade II B 34%
    PLANNING
    - release patient clothes
    -wound toilet using NaCl
    -IVFD RL loading 1000 cc  2000cc/24hours
    - Inj Ketorolac/8 hour
    - drip novalgin
    -salep antibiotic
    - monitoring urine produce (

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